rise to the left anterior descending (LAD) and left circumflex (LCX) arteries, and probably an intermedius artery.

Transcription

1 Heart Price : ` 5/- Honorary Editor : Left Main wi Multi Vessel PCI (in Case of Seropositive Illness wi Thrombocytopenia) Dr. Keyur Parikh Dr. Vipul Kapoor From e Desk of Hon. Editor: Considering lesion priority and its clinical consequences, Coronary Artery Bypass Grafting (CABG) has been a treatment of choice for revascularization in patients wi significant Left Main Coronary Artery (LMCA) disease. However, e patients wi severe Left Main stenosis have a very high risk of major cardiovascular events because of e extent of ischaemic myocardium. So, we can say at left main coronary artery disease is e most prognostically important coronary lesion. Significant stenosis of Left Main is diagnosed in 5 7% of patients undergoing coronary angiography. Considering lesion priority and its clinical consequences, Coronary Artery Bypass Grafting (CABG) has been a treatment of choice for revascularization in patients wi significant Left Main Coronary Artery (LMCA) disease. However, wi remarkable advancements in techniques of Percutaneous Coronary Intervention (PCI), supporting devices, and adjunctive pharmacologic erapy, PCI wi stenting has emerged to be a less invasive and feasible revascularization treatment for ese patients. This review attempts to highlight e indications, technique and treatment modalities for Left Main disease wi Multi Vessel PCI in Case of Seropositive Illness wi Thrombocytopenia. Background: The Left Main Coronary Artery (LMCA) supplies two-irds of blood to e heart and 100% of e blood flow to e left ventricle. The distal LMCA ends in a bifurcation, or even trifurcation, giving rise to e left anterior descending (LAD) and left circumflex (LCX) arteries, and probably an intermedius artery. Left Main Distal Bifurcation Lesion : 70% of significant LMCA lesions involve e distal bifurcation. Intimal aerosclerosis in e LMCA bifurcation is accelerated primarily in area of low shear stress in e lateral wall close to e LAD and LCX bifurcation. LMCA stenosis is e most challenging lesion in patients wi acute coronary syndromes placing e patient at high risk for life reatening LV dysfunction and arrhymias. Since e amount of myocardium at Cardiologists Cardiooracic & Vascular Surgeons Cardiac Anaesetists Dr. Satya Gupta (M) Dr. Milan Chag (M) Dr. Dhiren Shah (M) Dr. Chintan She (M) Dr. Vineet Sankhla (M) Dr. Urmil Shah (M) Dr. Dhaval Naik (M) Dr. Niren Bhavsar (M) Dr. Vipul Kapoor (M) Dr. Hemang Baxi (M) Dr. Amit Chandan (M) Dr. Hiren Dholakia (M) Dr. Tejas V. Patel (M) Dr. Anish Chandarana (M) Dr. Gunvant Patel (M) Dr. Ajay Naik (M) Pediatric & Structural Heart Surgeons Cardiac Electrophysiologist Dr. Keyur Parikh (M) Dr. Shaunak Shah (M) Dr. Ajay Naik (M) Dr. Vineet Sankhla (M) Congenital & Structural Heart Disease Specialist Cardiovascular, Thoracic & Neonatologist and Paediatric Intensivest Dr. Kashyap She (M) Dr. Milan Chag (M) Thoracoscopic Surgeon Dr. Divyesh Sadadiwala (M) Dr. Pranav Modi (M) Dr. Amit Chitaliya (M)

2 Heart risk is very high, e patient is often in cardiogenic shock, and e risk of dea is high and even more so in left dominant coronary system. Distal LMCA lesions are mostly treated as true bifurcation. The exception to is is when one branch is small (usually e LCX), when one branch is chronically occluded or if protected by a patent graft. In ese circumstances e distal lesion may be stented wi a single-stent technique, stenting across e ostium of e oer vessel. True bifurcation lesions may be treated eier by single-stent or by a two-stent strategy. Choice of strategy depends on vessel and lesion characteristics [plaque distribution, e diameter of e branches, e angle between em and anatomy of Side Branch (SB)]. The provisional stenting is a singlestent strategy, alough it allows e placement of a second stent if required [T, T and protrusion (TAP), culotte technique]. More complex lesions may require double-stent strategy (T stenting, TAP, mini-crush, double-kiss crush, culotte, V stenting). stenosis extending into ostia of bo branches n L M C A n o t l a rge e n o u g h to accommodate two stents n Angle Between LAD and LCX More Acute (<70 ) Advantages of Mini-Crush Stenting: n Applied in clinically unstable lesions and complex anatomies n Maintains patency of bo branches n Provides excellent coverage of SB S I G N I F I C A N C E O F M I N I C R U S H ostium STENTING n Allows access of SB wi wires and The crush technique can be used balloon when e diameter of e main vessel is n Better contact of SB struts against e greater an e side branch and e wall angulation is favorable (approximately Thrombocytopenia: Thrombocytopenia (TP) is associated wi a variety of etiologies. These include increased utilization or destruction, decreased bone marrow production, immune mechanisms, adverse drug effects, and infectious agents. 60%). The side branch is tented first, positioning e stent to allow 1 2 mm (Mini-Crush) to protrude into e Left Main. The main vessel is en stented. Deployment of e main vessel stent crushes e proximal side branch stent against e Left Main wall. It is necessary to rewire e LCX, rough e stent struts of bo e LAD and crushed LCX stent to perform a final post-dilatation of e side branch ostium and a final kissing balloon inflation. Selection Criteria for Mini-Crush Stenting: n Presence of significant bifurcation 2

3 Heart Classification of Thrombocytopenia Classification Platelet Count Mild <150??109/L but 100??109/L Moderate <100??109/L but 50??109/L Severe <50??109/L Seropositive illness wi Thrombocytopenia is a relatively rare finding, particularly in patients wi coronary artery disease. Percutaneous Coronary Intervention (PCI) as well as Coronary Artery Bypass Grafting (CABG) has traditionally not been an option for patients wi severe rombo-cytopenia, because ese patients are felt to be at increased risk for bleeding complications resulting from e required peri-procedural anticoagulation and post-procedural Dual Antiplatelet Therapy (DAPT). This speculation is indirectly supported by a recent study done by Overgaard CB et al. in which e baseline TP emerged as an independent predictor of mortality in patients undergoing PCI. Case Presentation : Patient Details : Gender Male Age 56 years History of : Hypertension Presentation : Chest pain Coronary Artery Disease Unstable Angina TMT Positive Triple Vessel Disease Fair LV Systolic Function Vitals : BP 110/70 mmhg HR 78 bpm Platelet Count : /cmm OR 39x 109/L Seropositive Illness ECHO Findings Normal sized LA, LV, RA, RV. LMCA 80% Occlusion LCX 70% Occlusion Before Angioplasty After Angioplasty Normal LV systolic function, LVEF: 55-60% No significant RWMA. Reduced LV compliance All cardiac valves are structurally normal. Mild MR (20%), mild TR, Trivial PR, No AR. Mild PAH, RVSP: 40 mm Hg. No clot/vegetation/pericardial effusion. No coarctation of aorta Angiography Report CORONARIES LMCA : Distal shows 70% lesion LAD : Proximal shows 60% lesion, Mid shows 80% lesion RAMUS : Mid shows diffuse disease LCX : Non Dominant, Origin shows 50% plaque, Proximal 70% lesion OM1 : Proximal shows 80% lesion RCA : Dominant, Proximal Mid shows 99% lesion Advised for PTCA + Stenting of LMCA LAD and LCX using DES Strategies to Minimize Bleeding Risk in Patients wi Significant Thrombocytopenia Avoid non-steroidal anti inflammatory drugs Avoid glycoprotein IIb/IIIa inhibitors Utilize a proton pump inhibitor unless contraindicated Aspirin should be used in low-dose. If a patient is already receiving a longterm anticoagulation agent, triple erapy should be avoided If a patient is undergoing percutaneous coronary intervention: o Radial approach preferred to femoral approach o Restrict dual antiplatelet erapy to 1?mon post-stent o Second generation drugeluting stent preferred to baremetal stent Take Home Message 3

4 Heart Coronary bifurcation disease is a very challenging subset in interventional cardiology. A provisional approach wi MB stenting is e preferred choice in most bifurcations lesions but it is very important to select e most appropriate approach for each bifurcation based on anatomical variables and operator experience. Regardless of strategy choice (one versus two stents), DES have dramatically improved e long term outcomes and should be e preferred device. We believe at e future perspective is primarily related to e development and refinement of dedicated bifurcation stents, which may simplify e procedure by adapting to e complex anatomy of bifurcation disease, and, at e same time, improving e long-term clinical outcomes. In patients wi severe TP, PCI is feasible and generally well tolerated. The main drawbacks are e bleeding complications, which are frequent and may have a negative clinical impact. Stenting of Unprotected stenosis can be performed wi good results in carefully selected patients. For e Unprotected bifurcation, single stent strategies are still preferred and should yield acceptable results for >80% of cases. Careful management wi e radial artery as e access site, DES implantation and a short DAPT protocol may help to improve eir outcome. Also, close monitoring is crucial to improve compliance wi erapy and minimize adverse events. Dr. Keyur Parikh MD (USA), FCSI (India), FACC (USA), FSCAI (USA) Interventional Cardiologist Mo Dr. Vipul Kapoor MBBS, MD (Gen.Medicine), DNB (Cardiology), MNAMS, FESC, FSCAI Interventional Cardiologist Mo CIMS Learning Centre Skills Development Centre ORAL CAVITY CANCER OVERVIEW Course Directors : Dr. Darshan Bhansali / Dr. Jayesh V. Patel / Dr. Tarang Patel Dr. Natu Patel / Dr. Devang Bhavsar Duration : 1 day Number of seats : 50 Venue : CIMS Auditorium August 12, 2018 (Sunday) Programme Overview: India is e capital country for oral cavity cancers. It is important to have a sound knowledge of oral cavity anatomy for good management and outcomes. This programme is crafted for all ose who deal wi oral cavity cancers and e updated knowledge on e management is e need of e hour. This course is helpful for ENT surgeons, dental surgeons, surgical residents. Programme Highlights: Ÿ Surgical anatomy and its implications Ÿ Diagnosis and paology of oral cancers alongwi outline of premalignant lesions Ÿ Factors affecting plan of treatment Ÿ Imaging-which, when and why Ÿ Reconstruction meods Ÿ Adjuvant (radiation & chemoerapy) treatments Online registration & payment on /clc Registration Fees: ` 500/- Spot Registration Fees: ` 1,000/- Non-refundable For any query, please on : clc@cimshospital.org > Certificate of attendance will be given at e end of e course. 4

5 International Centers Of Excellence Heart FEVER CLINIC HOSPITAL Got ese signs? DENGUE MALARIA CHIKUNGUNYA SWINE FLU (H1N1 INFLUENZA) Signs & Symptoms Signs & Symptoms Signs & Symptoms High Fever Muscle & Joint pains Pain behind e eyes Diarrhea & Vomiting Diarrhea & Vomiting Sweating Headache Nausea Fever Joint Pains Muscle Pains Skin Rashes Abdominal Pain Headache Shaking Chills - High Fever Nausea Chills and Rigors FEVER CLINIC HELPLINE ISOLATION UNIT One-of-its-kind Isolation Unit for Critically ill Patients We look forward to save lives. Signs & Symptoms High Fever Bodyache Headache and Malaise Cough and Cold Sore Throat Diarrhea Vomiting or Nausea Complications could occur due to Swine Flu and could involve different organs such as Lung injury, Pneumonia, Kidney Failure, Brain Infection, etc. Get Vaccinated Today Off. Science City Road, Ahmedabad Ph. : Fax : info@cims.org AMBULANCE : EMERGENCY : X 7 MEDICAL HELP LINE

6 Heart JIC 2019 January 4-6, Annual Scientific Symposium 24 Year of Academics Download Registration Form AN OFFER YOU SHOULDN'T MISS! And also a Special Master Class by Dr. Steven Nissen wi Early Registration Cancellation of Registration will be accepted upto November 30, 2018 Visit for more information GMERS Medical College, Sola, Ahmedabad 6

7 International Centers Of Excellence Heart CIM STEMI HOSPITAL FOR FAST LIFE-SAVING HEART TREATMENT What is STEMI? The most deadly type of Heart Attack where in coronary artery gets completely blocked Needs Prompt Treatment wiin 60 minutes* Pre-hospital and in-hospital management, and reperfusion strategies wiin 24 h of FMC European Society of Cardiology guidelines a STEMI diagnosis Primary-PCI capable center EMS or non primary-pci capable center Preferably < 60 min PCI possible < 120 min? Pharmacoinvasive Approach Immediately Preferably 3-24 h Primary-PCI Rescue-PCI No Yes Coronary angiography Successful fibrinolysis? Immediate transfer to PCI center Preferably 90 min ( 60 min in early presenters) Immediate transfer to PCI center Yes No Immediate fibrinolysis Preferably 30 min a The time point e diagnosis is confirmed wi patient history and ECG ideally wiin 10 min from e first medical contact (FMC). All delays are related to FMC (first medical contact). Ca = caeterization laboratory; EMS = emergency medical system; FMC=first medical contact; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction. ACC ACC - American College of Cardiology Centre of Excellence One of e only Centres in India for high-standards of medical practice and dedication in providing quality cardiovascular care *As early as possible after onset of Heart Attack (STEMI) 24 X 7 HELPLINE Off. Science City Road, Ahmedabad info@cims.org AMBULANCE : EMERGENCY :

8 Heart Heart Registered under RNI No. GUJENG/2008/28043 Published on 5 of every mon Permitted to post at PSO, Ahmedabad on e 12 to 17 of every mon under st Postal Registration No. GAMC-1725/ issued by SSP Ahmedabad valid upto 31 December, 2020 st Licence to Post Wiout Prepayment No. PMG/HQ/055/ valid upto 31 December, 2020 If undelivered Please Return to : CIMS Hospital, Nr. Shukan Mall, Off Science City Road, Sola, Ahmedabad Ph. : Fax: Mobile : , Subscribe Heart : Get your Heart, e information of e latest medical updates only ` 60/- for one year. To subscribe pay ` 60/- in cash or cheque/dd at CIMS Hospital Pvt. Ltd. Nr. Shukan Mall, Off Science City Road, Sola, Ahmedabad Phone : / Cheque/DD should be in e name of : CIMS Hospital Pvt. Ltd. Please provide your complete postal address wi pincode, phone, mobile and id along wi your subscription CIMS Learning Centre Skills Development Centre OPHTHALMOLOGY Course Director Duration Programme Overview: : Dr. Smita Dheer : 1 day Number of Seats : 50 Venue : CIMS Auditorium As Diabetes is one of e commonest ailment we come across as general practioners, we are going to discuss correlation of diabetic eye diseases (retinopay) wi glycemic control and nephropay. A multi-specialist team of ophalmologist, nephrologist and endocrinologist will form a panel at is course. Red Eyes and common eye problems will also be discussed to impact daily practice. Interesting cases will be presented to help in day to day clinical practice along wi an insight into cataract surgery how it has evolved, and what is e future. July 22, 2018 (Sunday) Online registration & payment on /clc Registration Fees: ` 500/- Spot Registration Fees: ` 1,000/- Non-refundable For any query, please on : clc@cimshospital.org > Certificate of attendance will be given at e end of e course. CIMS Hospital : Regd Office: Plot No.67/1, Opp. Panchamrut Bunglows, Nr. Shukan Mall, Off Science City Road, Sola, Ahmedabad Ph. : Fax: CIMS Hospital Pvt. Ltd. CIN : U85110GJ2001PTC info@cims.org Printed, Published and Edited by Dr. Keyur Parikh on behalf of e CIMS Hospital Printed at Hari Om Printery, 15/1, Nagori Estate, Opp. E.S.I. Dispensary, Dudheshwar Road, Ahmedabad Published from CIMS Hospital, Nr. Shukan Mall, Off Science City Road, Sola, Ahmedabad